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14 Articles in Volume 19, Issue #1
Analgesics of the Future: NKTR-181
Antidote to CDC Guideline; Plantar Fasciitis; Patient Input
Assessing and Treating Migraine in Women and Men
Demystifying Opioid-Induced Hyperalgesia
Editorial: Have We Gone Too Far? Can We Get Back?
How to Compel Patients to Complete Home Exercises
Inflammation Targeted Nanomedicine
Intravenous Stem Cell Administration for Ileitis
Invasive Surgery: Effective in Relieving Chronic Pain?
Pain Catastrophizing: What Practitioners Need to Know
Pain Therapy Options for the Home
Regenerative Medicine
The Future of Pain Management: An Experts' Roundtable
Whole Body Vibration: Potential Benefits in the Management of Pain and Physical Function

Antidote to CDC Guideline; Plantar Fasciitis; Patient Input

January/February 2019 PPM Letters to the Editor from practitioner peers and patients.
Pages 13-14

Journal as an Antidote to the CDC Guidelines

Dear PPM,

I cannot thank you enough for Practical Pain Management (PPM), a big umbrella covering diverse aspects of pain and its management. In a way, PPM is an “antidote” to the CDC’s guideline on prescribing opioids for chronic pain. I am sure [the guideline’s] writers meant well as they consulted experts in the field, but I wonder if they are all “desk” doctors unlike some of us who actually take care of those who suffer from pain.

My chronic pain patients include: several post-op hip/knee/ankle cases, a few fibromyalgia cases, and a letter carrier with neck/shoulder pain. I cannot cut them off pain medication. That would be cruel. Those of you at PPM have convinced me that I should follow the path of easing their pain and suffering through practical and sensible management.

–Yasuo Ishida, MD

Responses to Plantar Fasciitis Paper

Plantar Fasciitis: Diagnosis & Management: Applying an Osteopathic Approach” ran in PPM’s November 2018 issue by Kanumalla R, et al.

Dear PPM,

The introduction to this “Tips from the Field” article provided a brief review of some literature and I was expecting some practical information to follow. I am afraid that the management part of the discussion was lacking. As for diagnosis, current thought suggests that the build-up of cytokines in the area causes morning pain; this pain slightly improves from ambulation because of increased blood flow and washout of these cytokines in the heel area. Morning symptoms differ from tarsal tunnel syndrome, nerve entrapments, calcaneal fractures, etc.

Steroid injections are mentioned without any “tips” as to dose, type, and technique. Platelet-rich plasma injections, while expensive, should have received more mention and not been equated with nutritional supplements.

Ill-fitting shoes are a common problem and rigid, well-supportive shoes and inserts can help. Orthotics are useful but should be customized. OTC orthotics may be flimsy and non-supportive. Stretching exercises are helpful but are specific; no details were given. The discussion of HVLA and trigger point injections made no sense as the plantar fascia is a ligament. Are people dry needling for plantar fasciitis?

If all else fails, plantar fascial release surgery should be a last option. New approaches are minimally invasive and normal weight bearing can resume about 3 weeks after surgery. Overall, the article made no mention of detailed diagnosis and management of this common condition. I would have liked to hear more about the authors’ results.

–Robert Rogoff, MD, and Lauren Schnack, DPM

Dear Drs. Rogoff and Schnack,

Thank you for your questions regarding our article. Our goal was to present an osteopathic approach to plantar fasciitis, which includes generalized podiatric and orthopedic treatments, but based upon limits to the length of the article, we focused more on osteopathic manipulation realizing that many pain providers may be less familiar with this option and resulting in leaving some gaps in other treatment details as you pointed out.

–Drs. Shoup, Keane, Mauro, and Goldstein with Student Doctors Kanumalla & Matsushita

Dear PPM,

Due to their scope of practice and focus, podiatrists see the majority of plantar fasciitis cases that present for professional care. I wrote an article for this publication (June 2011) outlining common podiatric approaches regarding the treatment of this common condition. The recent article in PPM by Kanumalla, et al, presents an excellent description of the pathophysiology of acute and chronic plantar fasciitis. I am curious as to the number of patient visits and duration of treatment time required to undergo the osteopathic treatments described in this article.

–Evan F. Meltzer, DPM

Dear Dr. Meltzer,

Thank you for bringing your article from June 2011 to our attention. In our osteopathic approach to plantar fasciitis, osteopathic manipulative treatment can be effective in as little as one treatment, although a few repeat treatments at weekly intervals may be necessary to resolve the problem. This being said, osteopathic manipulation alone may not offer complete resolution if foot/shoe mechanics are not addressed. So, a comprehensive approach including orthotics and podiatric referral is appreciated.

–Drs. Shoup, Keane, Mauro, and Goldstein with Student Doctors Kanumalla & Matsushita

From Our Patient Readers

Diet Matters

Glad to see your article on diet and chronic pain in the November issue (“Can Nutritional Management Make a Dent in Pain Relief?”). I am a chronic pain patient and diet has been part of the foundation for my Overdose Risk Reduction (ORR) strategy that has been 100% effective for me in the 20 years I’ve taken opioids for polyosteoarthritis and related conditions. My 11-point ORR uses diet, relative exercise, restful sleep and no alcohol or other substances. I developed the strategy on my own; it’s empirical science. A person has to live a “clean life” when taking opioids and concentrating on diet can perhaps replace any obsession with the “feelings” associated with opioids.

I hunt for a balance of inexpensive foods at stores and prepare my meals using fresh foods from scratch. It takes time, but it gives me purpose and meaning so that I don’t just want to take drugs. I am disabled and, hence, relatively poor, so the foundation allows me to spend my money wisely. I assert that doctors can teach such techniques to their pain patients, as you good folks are doing. For instance, teaching physicians to teach patients about their awareness of the “prequelae” to an overdose?

–Charles Bruscino, an independent advocate for those with disabilities

Cannabis for RA & Migraine

Hello, I am a 59-year-old kindergarten teacher diagnosed with a form of rheumatoid arthritis. I play the flute in our community band as well, which is getting more and more difficult due to my arthritis. Lately, my shoulder has become inflamed and very painful, especially when I play my flute or use a computer mouse for an extended period of time. I cannot take opioids because they make me itch. Besides, they didn’t really work. I have also tried a variety of biologics where I gave myself injections. These did not seem to work either, and had serious side effects as well.

So, in desperation, I decided to visit my local cannabis dispensary to see if they could help me. To be honest, I did not hold very high expectations. I have to say that I was pleasantly surprised! The very nice young man at the store took the time to set me up with a tincture and a topical that addressed not only my issues but my whole body. The pain relief I have experienced is phenomenal! I did not at all expect this degree of relief! Consequently, I have just started to research the medical marijuana side of cannabis, which is what brought me to the PPM site (more on cannabis and pain). I am so happy with the results, that I had to share them!

–Robin L.

I am a chronic pain sufferer, have been for years. You could say I have tried everything out there to relieve my pain. Sometimes it works, and sometimes it doesn’t.... This is what I found out.

I have three types of migraine: ice pick, complex, and hemiplegic/stroke. Boy, are they fun when they decide to all gang up on me at once! I have tried gels, icepacks, pills, creams, you name it, even Botox shots. Off the top, garden variety Tylenol, Advil, etc, couldn’t cut it, not even a dent; I was feeling groggy, gross, and still in pain. Prescribed meds weren’t much better. Although they were more powerful and helped take most of the pain away a lot of the time, the havoc they wrecked on my body was tremendous!

Enter Botox: some injections along the perimeter of the hairline, and around the scalp, neckline and forehead left me sitting pretty pain-free for 3 months. However, this treatment didn’t quite cure my hemiplegic migraine...it’s a mystery as to when the next one will come and having different triggers makes it difficult. The right side of my body becomes “paralyzed” temporarily, whether that is 3 hours or 3 days; it comes with some intense sharp pain, drooping right facial features, an unresponsive right arm and sometimes my right leg joins the “party.”

CBD oil, however, has truly been a game changer for me in recent months. I feel like I am gaining control over my life again, not 100%, but it is progress and I have to stay positive!

–Lisa Koyle

Light Therapy

I have trigeminal neuralgia and understand that red light therapy/photobiomodulation is being used to help alleviate such pain. I also had a recent hip replacement due to a fall and have inflammation in my spine and neck as shown on a thermography scan. I’m looking for any information that you can pass along to me about this.

–Pamela Luckey

I am recovering from traumatic brain injury and seeking treatments. Can you recommend or provide references for low light therapy in the San Francisco Bay Area?

–Rosemary L.

Last updated on: February 4, 2019
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Naloxone in Schools; Buprenorphine Conversions; OUD Management
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